Injectable Contraceptives: Tools for Providers ore than twice as many women are using Minjectable contraceptives today as a decade ago, and the numbers keep growing. Women choose injectables because they are highly effective, long-acting, reversible, and private. At the same time many women do not choose injectables or stop using them because of side INFO Project effects—particularly irregular bleeding, no Center for Communication monthly bleeding, and weight gain—or because Programs they have trouble returning for injections (13, 70, 135, 168). Family planning programs are meeting increasing demand while helping providers to maintain good quality of care. Attention to quality, and to counseling especially, can be the difference between successful and unsuccessful efforts to expand access to injectables (77, 78). Using the tools in this INFO Reports, providers can inform women about injectables and help them be satisfi ed users. Table 1. Formulations and Injection Schedules of Injectable Contraceptives Common Trade Names Formulation Injection Type and Schedule Coming Soon: Progestin-Only Injectables “Injectables Toolkit” ® ® Web site. Go to www. Depo-Provera , Megestron , Depot medroxyprogesterone acetate One intramuscular (IM) injection Contracep®, Depo-Prodasone® (DMPA) 150 mg every 3 months injectablestoolkit.org for job aids One subcutaneous injection every depo-subQ provera 104® (DMPA-SC) DMPA 104 mg and information 3 months about injectable Norethisterone enanthate (NET-EN) Noristerat®, Norigest®, Doryxas® One IM injection every 2 months contraceptives 200 mg Combined Injectables (progestin + estrogen)1 Medroxyprogesterone acetate 25 mg + Cyclofem®, Ciclofeminina®, Lunelle® 2 One IM injection every month Estradiol cypionate 5 mg (MPA/E2C) NET-EN 50 mg + Estradiol valerate Mesigyna®, Norigynon® One IM injection every month 5 mg (NET-EN/E2V) Deladroxate®, Perlutal®, Dihydroxyprogesterone (algestone) Topasel®, Patectro®, Deproxone®, acetophenide 150 mg + Estradiol One IM injection every month Nomagest® enanthate 10 mg Dihydroxyprogesterone (algestone) Anafertin®, Yectames® acetophenide 75 mg + Estradiol One IM injection every month enanthate 5 mg Chinese Injectable No. 1® 17α-hydroxyprogesterone caproate One IM injection every month, 250 mg + Estradiol valerate 5 mg except 2 injections in fi rst month Sources: International Planned Parenthood Federation 2005 (83), Lande 1995 (99), Liggeri 2006 (103), WHO 1990 (204), WHO 1993 (205) 1Also called monthly injectables. 2The U.S. Food and Drug Administration approved Lunelle, but it is currently not available in the United States. See companion Population Reports, “Expanding Services for Injectables” December 2006 • Issue No. 8 205402_JHU-InfoReport.indd 1 12/12/06 10:52:44 AM Checklist for Giving Intramuscular How to Use This Report Family planning providers can use the checklists Contraceptive Injections and tables in this report to: Family planning providers can use this checklist to help ensure • Counsel about injectables or answer clients’ questions (see Table 2, pp. 3–4), that injections are safe. ˛ • Identify women who may not be able to use DMPA or NET-EN for medical reasons (see Prepare equipment and supplies Checklist, pp. 5–6), • Be reasonably sure that a woman is not preg- q In advance, assemble the supplies and materials needed nant before giving the fi rst injection (see Checklist, p. 6, questions 8–13), •Single-dose vial • Review the steps required to give an injection •Sterile needle and syringe (If auto-disable (AD) or conventional disposable safely (see Checklist, this page), and syringes and needles are not available, use sterile equipment designed • Help women be informed and satisfi ed con- for steam sterilization. Do not reuse disposable equipment.) tinuing users of injectables (see Table 3, p. 7). •Cotton wool This report accompanies Population Reports, “Expanding Services for Injectables”. q Wash hands with soap and water before giving the injection, if possible. Gloves See also Population Reports, “When are not needed unless there is a chance of direct contact with blood or other Contraceptives Change Monthly Bleeding,” Series J, No. 54, August 2006. body fl uids. q Inspect the vial and check expiry date. Discard any with visible cracks or leaks. This report was prepared by Robert Lande q With injectables containing DMPA, roll the vial back and forth or gently shake to and Catherine Richey, MPH. mix contents. If the vial of NET-EN is cold, warm to skin temperature before giving Ward Rinehart, Editor. Rafael Avila and Francine Mueller, Designers. the injection. The INFO Project appreciates the assistance Intramuscular injections can be given of the following reviewers: Jacob Adetunji, in the deltoid muscle of either arm Kim Best, Richard Blackburn, Marc G. or the left or right buttock (gluteal Boulay, Steve Brooke, Gloria Coe, María muscle, upper outer portion), del Carmen Cravioto, Juan Díaz, Maxine whichever the woman prefers.1 To Eber, Douglas Huber, Barbara Janowitz, minimize the risk of injury, providers Sophie Logez, Enriquito R. Lu, Kuhu Maitra, Kavita Nanda, Fredrick Ndede, Carib should take care to deliver the Nelson, Paula Nersesian, Gael O’Sullivan, injection in the proper site. Joseph F. Perz, James Phillips, Roberto Rivera, Ruwaida Salem, Hilary Schwandt, Give the injection safely Stephen Settimi, James D. Shelton, Jenni Smit, Cathy Solter, J. Joseph Speidel, Jeff Spieler, Tara M. Sullivan, Jagdish Upadhyay, q Explain the injection procedure to the client and point out that the syringe and Ushma Upadhyay, Marcel Vekemans, Irina Yacobson, and Vera Zlidar. needle are sterile. Suggested citation: Lande, R. and Richey, C. q Ask the client her preferred site for injection: upper arm (deltoid muscle) or “Injectable Contraceptives: Tools for Provid- buttocks (gluteal muscle). To decrease discomfort, position her so that her ers,” INFO Reports, No. 8. Baltimore, Johns Hopkins Bloomberg School of muscles are relaxed. Public Health, INFO Project, Dec. 2006. q Wash the injection site with soap and water if it is visibly dirty. Swabbing clean skin Available online: http://www.infoforhealth.org/inforeports/ or wiping the skin with antiseptic before giving an injection is not necessary. q Pierce the top of the vial with the sterile needle and fi ll syringe with the proper dose. q With a smooth, steady motion, insert the needle deep into the muscle at a right angle (90°) and inject the contents of the syringe. INFO Project Center for Communication Programs q After the injection ask the client to hold cotton wool on the injection site. Instruct Johns Hopkins Bloomberg School of Public Health the client not to massage the injection site. 111 Market Place, Suite 310 Baltimore, Maryland 21202 USA q Wash hands with soap and water after giving the injection, if possible. 410.659.6300 410.659.6266 (fax) www.infoforhealth.org Dispose of waste appropriately [email protected] Earle Lawrence, Project Director, INFO Project; Do not recap, bend, cut, or break needles after use. Discard the used disposable Stephen Goldstein, Chief, Publications Division; q Theresa Norton, Associate Editor; needle and syringe immediately in an enclosed sharps container. Linda Sadler, Production Manager. q If reusable syringes and needles are used, they must be sterilized again after INFO Reports is designed to provide an accurate and authoritative report on important developments each use. in family planning and related health issues. The opinions expressed herein are those of the authors q Seal and dispose of sharps containers when they are three-fourths full. and do not necessarily refl ect the views of the U.S. Follow program or clinic guidelines for proper waste management. Agency for International Development (USAID) or the Johns Hopkins University. Adapted from: Hutin 2003 (80) Published with support from USAID, Global, GH/POP/PEC, 1Intramuscular injection of the combined injectable Cyclofem can also be given in the thigh (lateral muscle of the quadriceps). under the terms of Grant No. GPH-A-00-02-00003-00. 2 205402_JHU-InfoReport.indd 2 12/12/06 10:57:31 AM 205402_JHU-InfoReport.indd TableChoiceofInjectableContraceptives2.HelpingClientsMakeaWell-Informed safetyandsideeffects,Effectiveness, acontraceptivemethod(27,55,227).Whentheyareseekthefactorsthatwomenconsidermostimportantwhenchoose familyplanningservices,mostwomenalreadyhaveamethodinmindthatintereststhem (198). Increasingly, thatmethodisaninjectablecontraceptive.Good -quality programsandknowshowitisused.Counselingalsohelpsaassuredofitssafety,sideeffects,ensurethatwomaninterestedinaninjectableunderstandseffectiveness 3 womanThisinformationtohelpwomenwiththeirdecisiontableoffersdecideifthemethodsuitsherneeds,preferences,andcurrentsituation. -making. Progestin-Only Injectables 1 Combined Injectables KEY POINTS:Givewomenthisinformation Womenneedthis •contraceptivemethods.Oneofthemosteffective •contraceptivemethods.Oneofthemosteffective information tomake •haveaninjectionevery3monthsforDMPAWomen Importantorevery2monthsforNET-EN. •haveaninjectiononceamonth.ImportanttoWomen an informedchoice totrybeontimeforthenextinjection. trytobeontimeforthenextinjection. about injectables • Mostwomenhavefrequentorirregularbleedingat first andthenlittleornomonthlybleeding. • tochangebleedingpatternsunpredictablyduringLikely Thisisnotharmful.Gradualweightgaincommonand the firstAfterThis3isnotharmful.monthsofuse. •take4monthslongeronaveragetobecomepregnantafterstoppingDMPAWomen thanafter monthsmostwomenhaveregularpatterns(around stoppingmethodsotherthaninjectables.